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Tripathi M, Maskara P, Deora H, Bansal D, Mohindra S, Tripathi S, Kaur R, Sheehan JP, Rana R, Kumar N. Role of Stereotactic Radiosurgery in Intracranial Histiocytosis: a Systematic Review of Literature of an Emerging Modality for Localized Disease. World Neurosurg 2021; 150:64-70. [PMID: 33744421 DOI: 10.1016/j.wneu.2021.03.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND A histiocytosis is a group of immunoproliferative disorders of clonal cells. The management protocols are still evolving, with chemotherapy as the mainstay of treatment. OBJECTIVE This study aims to evaluate the feasibility, safety, efficacy, and complication profile of stereotactic radiosurgery for intracranial histiocytosis. METHODOLOGY The authors reviewed PubMed, Scopus, Web of Science, and Embase for "radiosurgery" and "histiocytosis" in the English/Japanese language following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The patient profile, radiosurgical parameters (dose and isodose), target volume, and mode of radiosurgery (Gamma knife, LINAC radiosurgery, etc.) were collected. Its use as primary or adjuvant therapy, clinical and radiological outcome was also evaluated. RESULTS We identified 7 studies (9 patients); mean age: 41.9 years (24-57 years). Six patients received Gamma-knife radiosurgery, whereas 3 received CyberKnife radiosurgery. The Langerhans cell histiocytosis variants were eosinophilic granuloma in 3, whereas 4 were not defined. Two cases had Rosai-Dorfman disease, and 2 different yet pathogenetically related histiocytic disorders. Four patients harbored lesions in the pituitary stalk and posterior pituitary, 2 patients in the petrous region, 1 patient had a pontine lesion, and 2 patients had multiple lesions. The dose delivered ranged from 8 to 28 Gy. A total of 18 lesions (9 patients) were followed for 81.67 patient-years: 7 (39%) disappeared, 8 (44.4%) showed radiological reduction, and 2 (11%) remained stable. One lesion (5%) showed an increase in size needed surgical excision. There were no adverse effects. CONCLUSION The role of stereotactic radiosurgery needs to be further evaluated as the current cohort with only 9 cases (2 are Rosai-Dorfman disease) is insufficient to make conclusions. It may be a viable alternative in localized disease, along with chemotherapy and targeted surgery.
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Affiliation(s)
- Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
| | - Prasant Maskara
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Deepak Bansal
- Hematology/Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sandeep Mohindra
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | | | - Rupinder Kaur
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ruchita Rana
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Narendra Kumar
- Department of Radiation Therapy, Postgraduate Institute of Medical Education and Research, Chandigarh.
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Eng TY, Abugideiri M, Chen TW, Madden N, Morgan T, Tanenbaum D, Wandrey N, Westergaard S, Xu K, Jane Sudmeier L. Radiation Therapy for Benign Disease. Hematol Oncol Clin North Am 2020; 34:205-227. [DOI: 10.1016/j.hoc.2019.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Laird J, Ma J, Chau K, Chelius M, Shi W, Zhang Z, Lok BH, Yahalom J. Outcome After Radiation Therapy for Langerhans Cell Histiocytosis Is Dependent on Site of Involvement. Int J Radiat Oncol Biol Phys 2017; 100:670-678. [PMID: 29413280 DOI: 10.1016/j.ijrobp.2017.10.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE To characterize the efficacy and safety of radiation therapy in a contemporary Langerhans cell histiocytosis (LCH) cohort and to explore whether there are sites at higher risk for local recurrence. PATIENTS AND METHODS Between 1995 and 2015 we identified 39 consecutive LCH patients who were treated primarily with radiation therapy. Patients were staged by single/multisystem involvement and established risk organ criteria. In 46 irradiated lesions, clinical and radiologic responses were evaluated at multiple time points after radiation therapy. Patient demographics, treatment, and local failure were compared by site of lesion. RESULTS Median age at radiation therapy was 35 years (range, 1.5-67 years). Twelve patients had multisystem involvement, and of those, 5 patients had disease in organs considered to be high risk. The following sites were irradiated: bone (31), brain (6), skin (3), lymph node (3), thyroid (2), and nasopharynx (1). Median dose was 11.4 Gy (range, 7.5-50.4 Gy). At a median follow-up of 45 months (range, 6-199 months), local recurrence or progression was noted in 5 of 46 lesions (11%). There were no local failures of the 31 bone lesions evaluated, whereas the 3-year freedom from local failure in the 15 non-bone lesions was 63% (95% confidence interval 32-83%; P=.0008). Local failures occurred in 2 of 3 skin lesions, in 2 of 6 brain lesions, and 1 of 3 lymph node lesions. Deaths were recorded in 5 of 39 patients (13%), all of whom were adults with multisystem disease. CONCLUSION Radiation therapy is a safe and effective measure for providing local control of LCH involving the bone. Whereas bone lesions are well controlled with low doses of radiation, disease in other tissues, such as the skin and brain, may require higher doses of radiation or additional treatment modalities.
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Affiliation(s)
- James Laird
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; New York University School of Medicine, New York, New York
| | - Jennifer Ma
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Karen Chau
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Chelius
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Weiji Shi
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin H Lok
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Leveson J, Bourque JM, Lukovic J, Dar AR. Radiotherapy for Langerhans Cell Histiocytosis of Bilateral Eyelids. Cureus 2016; 8:e474. [PMID: 27004151 PMCID: PMC4779081 DOI: 10.7759/cureus.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 02/02/2016] [Indexed: 11/30/2022] Open
Abstract
Langerhans cell histiocytosis (LCH) is a rare disorder with numerous clinicopathological variants with differing clinical courses, treatment methods, and prognoses. We report one patient with atypical LCH of the bilateral lower eyelids and subsequent successful treatment with local radiation therapy.
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Affiliation(s)
| | | | - Jelena Lukovic
- Department of Radiation Oncology, London Regional Cancer Program
| | - A Rashid Dar
- Department of Radiation Oncology, London Regional Cancer Program
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Bumpass DB, Park A, Hill KT, Huang J, Friedman MV, Zebala LP. Eosinophilic granuloma of the sacrum treated with radiation therapy: a case report. Spine J 2016; 16:e53-7. [PMID: 26386170 DOI: 10.1016/j.spinee.2015.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/11/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Eosinophilic granulomas (EGs) of the sacrum have been reported in fewer than 10 patients. Treatment algorithms for these tumors remain poorly defined; there are no reports of treating solitary sacral EG with radiation therapy (RT). PURPOSE This study aimed to describe the presentation, treatment, and outcome of sacral EG in an adult patient with intractable pain and radiculopathy, treated in a novel fashion with RT. STUDY DESIGN/SETTING The study design was a case report from a tertiary cancer referral center. METHODS Patient records, imaging, and pathology were reviewed. RESULTS A 35-year-old man received 20 Gy of radiation to his S1 EG lesion. He subsequently developed vertebra plana of S1 causing symptomatic L5-S1 stenosis, but 15 months after RT treatment was free of pain or tumor recurrence. CONCLUSION Radiation therapy is an effective treatment option for sacral EG causing severe axial pain and neural impingement.
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Affiliation(s)
- David B Bumpass
- Department of Orthopaedic Surgery, Washington University, 660 S. Euclid Ave, Campus Box 8233, St. Louis, MO 63110, USA.
| | - Andrew Park
- Department of Orthopaedic Surgery, Washington University, 660 S. Euclid Ave, Campus Box 8233, St. Louis, MO 63110, USA
| | - Kirk T Hill
- Department of Pathology, Washington University, 660 S. Euclid Ave, Campus Box 8118, St. Louis, MO 63110, USA
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University, 660 S. Euclid Ave, Campus Box 8224, St. Louis, MO 63110, USA
| | - Michael V Friedman
- Mallinckrodt Institute of Radiology, Washington University, 660 S. Euclid Ave, Campus Box 8131, St. Louis, MO 63110, USA
| | - Lukas P Zebala
- Department of Orthopaedic Surgery, Washington University, 660 S. Euclid Ave, Campus Box 8233, St. Louis, MO 63110, USA
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Oza N, Sanghvi K, Menon S, Pant V, Patil M, Kane S. Cytological Diagnostic Approach in 3 Cases of Langerhans Cell Histiocytosis Presenting Primarily as a Thyroid Mass. Acta Cytol 2015; 59:418-24. [PMID: 26496501 DOI: 10.1159/000440969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/04/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Langerhans cell histiocytosis (LCH) is a monoclonal disease of specialised histiocytes characterised by the proliferation of neoplastic Langerhans cells (LCs) with a varying admixture of mature lymphocytes, eosinophils and plasma cells. LCH commonly occurs in the paediatric population and young adults with the involvement of bone, skin and lymph nodes. LCH has a protracted clinical course with an overall mortality rate of 3%. Primary involvement of the thyroid gland in LCH at presentation is a rare phenomenon that can result in misdiagnosis with consequent mismanagement. CASE Ultrasound-guided fine-needle aspiration cytology (FNAC) of the thyroid was performed in 3 cases at a tertiary cancer centre, including 2 referral cases where the patient presented with the only symptom of progressive thyroid enlargement. These cases were reported initially or on review and the results were correlated with histology/ancillary techniques. A cytological diagnosis of suspicion for LCH was offered in 2 cases at our centre and 1 case was referred to our centre with a diagnosis of suspected papillary thyroid carcinoma. On review of outside smears at our centre, the diagnosis was changed to suspected LCH. The diagnosis was confirmed by immunopositivity for CD68, CD1a and S100 in 1 case and Tru-cut biopsy followed by immunohistochemistry for CD1a, S100, TTF-1 and LCA in the other 2 cases. CONCLUSION FNAC was helpful in accurately diagnosing LCH even though the presentation was unusual. Thus, unnecessary surgery was obviated.
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Affiliation(s)
- Nikita Oza
- Department of Cytopathology, Tata Memorial Hospital, Mumbai, India
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Clinical outcomes of radiation therapy in the management of Langerhans cell histiocytosis. Am J Clin Oncol 2015; 37:592-6. [PMID: 23466581 DOI: 10.1097/coc.0b013e318281d6ce] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Langerhans cell histiocytosis (LCH) is a rare disease with variable clinical presentation. In the present study, we report on the effectiveness and clinical complications of radiation therapy in children with LCH. MATERIALS AND METHODS We retrospectively reviewed all patients with LCH treated with radiation therapy over a 6-decade period at a single institution. Radiotherapy data, clinical features, radiographic data, and vital status were analyzed. RESULTS The mean age at diagnosis for 69 patients was 5.3 years (3 mo to 37 y) and the median duration of follow-up was 6 years (7 d to 32 y). Radiation therapy was performed for 169 sites, primarily bone lesions. The median radiotherapy dose was 10 Gy (2.5 to 45 Gy). Radiographic follow-up data were available for 139 of the sites treated and clinical follow-up was available for 156 of sites treated. The radiographic local control was 91.4%, and 13% of lesions showed complete sclerosis or reconstitution of bone. A total of 90.4% of patients reported stabilization or improvement in lesion-related symptoms, most often pain. Twelve patients had diabetes insipidus at diagnosis or during follow-up. Eight of these patients received radiation treatment to the pituitary and none experienced a reduction in desmopressin dosage posttreatment. Radiation complications were few, including femoral neck fracture in 1 patient and facial asymmetry in 3 patients. No secondary malignancies were observed. CONCLUSIONS Radiotherapy for LCH has high rates of local control and symptomatic improvement. Importantly, however, there is evidence of short-term and long-term morbidity when children are treated with low-dose irradiation.
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Mondal D, Julka PK, Jana M, Walia R, Chaudhuri T. Langerhans cell histiocytosis of atlantoaxial joint in a middle-aged man presenting with deafness as first symptom and soft-tissue mass at neck showing excellent response to radiotherapy alone: Report of an extremely rare and unusual clinical condition and review of literature. Ann Indian Acad Neurol 2014; 17:429-32. [PMID: 25506166 PMCID: PMC4251018 DOI: 10.4103/0972-2327.144022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 02/23/2014] [Accepted: 03/02/2014] [Indexed: 11/18/2022] Open
Abstract
Langerhans cell histiocytosis (LCH) is a disorder of clonal proliferation of dendritic cell mainly occurring in children. Spine involvement is rare. This usually presents with pain and torticollis when neck is involved. Histopathology with immunohistochemistry is confirmatory. Local curative therapy with excision or curettage is used for localized disease. Radiotherapy is usually reserved for selected cases. Systemic chemotherapy is the treatment of choice for widespread systemic disease. In this article, we present an unusual presentation of atlantoaxial LCH with mastoid involvement resulting in hearing loss as the first symptom and quadruparesis in a middle aged male patient, which was also associated with soft-tissue mass at the nape of the neck and deafness. The patient was treated with radical radiotherapy, which provided excellent response to the disease. Involvement of atlantoaxial joint and temporal bone associated with soft-tissue mass neck and deafness in a middle-aged man is an extremely rare clinical situation.
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Affiliation(s)
- Dodul Mondal
- Department of Radiation Oncology, DRBRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - P K Julka
- Department of Radiation Oncology, DRBRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis, DRBRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Ritika Walia
- Department of Pathology, DRBRAIRCH, All India Institute of Medical Sciences, New Delhi, India
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Langerhans cell histiocytosis of the cranial base: is low-dose radiotherapy effective? Case Rep Oncol Med 2012; 2012:789640. [PMID: 22953095 PMCID: PMC3431053 DOI: 10.1155/2012/789640] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 07/25/2012] [Indexed: 12/18/2022] Open
Abstract
Introduction. Langerhans cell histiocytosis (LCH) is a rare disease of unknown etiology with different clinical features. A standardised treatment has not been established so far. Case Report. We report a case of a 28-year-old patient who initially presented with hypesthesia of the fifth cranial nerve and pain of the left ear. Diagnosis showed a tumour localised in the cranial base with a maximum diameter of 4.1 cm. The diagnosis of LCH was confirmed histologically by biopsy. Diagnostic workup verified the cranial lesion as the sole manifestation of LCH. A total dose of 9 Gy (single dose 1.8 Gy) was delivered. The symptoms dissolved completely within 6 months after radiation; repeated CT and MRI scans revealed a reduction in size of the lesion and a remineralisation of the bone. After a followup of 13 years the patient remains free of symptoms without relapse or any side effects from therapy. Discussion. Due to the indolent course of the disease with a high rate of spontaneous remissions the choice of treatment strongly depends on the individual clinical situation. In the presented case low-dose radiotherapy was sufficient to obtain long-term local control in a region with critical structures and tissues.
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Patten DK, Wani Z, Tolley N. Solitary langerhans histiocytosis of the thyroid gland: a case report and literature review. Head Neck Pathol 2011; 6:279-89. [PMID: 22198822 PMCID: PMC3370016 DOI: 10.1007/s12105-011-0321-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 12/12/2011] [Indexed: 11/25/2022]
Abstract
Langerhans cell histiocytosis (LCH) is a rare disease of antigen presenting cells, with an incidence rate of 4.0-5.4 per 1 million individuals. The most common endocrinological manifestation of classical LCH is associated with the posterior pituitary, presenting as Diabetes Insipidus. However, LCH can affect multiple organs and classification is based on the body system involvement. The disease is confirmed by electron microscopy or immunohistochemical reactivity of histiocytes to CD1a and/or S100. LCH rarely involves the thyroid gland, and management of such disease is controversial. Current literature documents 65 English language reported cases of LCH involving the thyroid gland. We present an unusual case of LCH of the thyroid gland, with variable diagnoses on fine needle aspiration (FNA) cytology, and literature review of all English reported cases.
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Affiliation(s)
- Darren K Patten
- Department of Biosurgery and Surgical Oncology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK.
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Gaundong Mbéthé GL, Dejean C, Henriques de Figueiredo B, Sargos P, Italiano A, Kantor G. [Multifocal Langerhans cell histiocytosis of bone: indications for radiotherapy]. Cancer Radiother 2010; 14:759-62. [PMID: 20674449 DOI: 10.1016/j.canrad.2010.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 01/22/2010] [Accepted: 03/24/2010] [Indexed: 10/19/2022]
Abstract
Langerhans cell histiocytosis is a non-malignant proliferative disease of unknown etiology that can affect one or more organs. This is a rare disease, 1 to 2/100,000, affecting mainly children with a male predominance. The osseous lesions are the most frequent (60 to 90%). There is however no consensus treatment for the management of these sites. We report the cases of two patients successfully treated with radiotherapy after primary chemotherapy, at doses of 15 Gy in ten sessions of 1.5 Gy for one patient and 18 Gy in ten fractions of 1.8 Gy for the other. Single or multifocal bone Langerhans cell histiocytosis without visceral involvement is a benign, self-limiting affection in most cases. Some bone lesions could be treated by radiotherapy alone. But the high variability of doses currently given in the literature does not allow determining the lowest effective dose limiting the risk of secondary neoplasia or impaired growth in children, in whom lower doses of 6 to 8 Gy are recommended. The decision of radiotherapy must be weighed against the risk of the disease. Caution should be the rule in this non-malignant tumour pathology.
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Affiliation(s)
- G-L Gaundong Mbéthé
- Service de radiothérapie, centre régional de lutte contre le cancer, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
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Eosinophilic granuloma of spine in adults: a report of 30 cases and outcome. Acta Neurochir (Wien) 2010; 152:1129-37. [PMID: 20396916 DOI: 10.1007/s00701-010-0644-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Accepted: 03/17/2010] [Indexed: 12/28/2022]
Abstract
BACKGROUND Eosinophilic granuloma (EG) of the spine is rare, especially in adults. There had been few large and long-term studies reported in the literature. The management goals of this disease in adults are preservation of neurologic function, relief of pain and reconstruction of spinal stability. However, there are still controversies over appropriate management modality of eosinophilic granuloma. METHODS Clinical manifestations, radiographic presentations, therapeutic outcomes and follow-up findings of 30 adults who were histiologically diagnosed with spinal eosinophilic granuloma, including 28 patients who received surgical treatment at our institutions from 1985 to 2008 were reviewed retrospectively. RESULTS There were 25 males and five females with a mean age of 34.5 years (range, 18-71 years). The post-operative follow-up period ranged from 2 to 22.4 years (mean, 8.3 years). Neurologic deficits developed in 21 patients, apparent kyphosis developed in four cases. In contrast to the classic feature of vertebra plana in children, we found that more severe lesions often led to asymmetric collapse in adult patients and only three patients presented with vertebra plana. Thirty-three vertebral lesions distributed throughout the spine column. Twenty-one lesions were in cervical spine, seven in the thoracic spine and five in the lumbar spine. Twenty-eight adult patients underwent surgical resection with or without chemotherapy or radiotherapy, and four (13.3%) patients had recurrence after surgery. No patient in our series died. CONCLUSIONS The onset of spinal EG is insidious and mainly presents as osteolytic destruction. There is a particular high prevalence of lesions in the cervical spine and more severe lesions often led to asymmetric collapse. As the skeleton of adults is well-developed and the epiphysis has stopped growing, individualized management including surgical intervention should be considered in adult patients with spinal EG who present with neurological damage and spinal instability.
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Abstract
The clinical manifestations of Langerhans cell histiocytosis have been recognized for more than a century. For most of that time, physicians have viewed the disease from different perspectives, interpreting portions of its clinical spectrum as if they were distinct and unrelated entities. More recently, Langerhans cell histiocytosis has been unified into a single concept, though the disease continues to defy traditional classification. By most accounts, Langerhans cell histiocytosis appears to be a morphologically benign proliferation of inflammatory cells that escapes regulatory control mechanisms. Studies from patients with all stages of the disease, however, document clonal proliferation of immune processing cells (i.e., Langerhans cells), suggesting a malignant disease process. The most common ophthalmic manifestation of Langerhans cell histiocytosis is a solitary lesion of orbital bone, which typically responds to minimally invasive therapy. The best management of solitary orbital Langerhans cell histiocytosis is debatable and has been complicated by its recent designation as a risk factor for central nervous system disease. This article summarizes recent developments in understanding the biology of Langerhans cell histiocytosis, reviews its ophthalmic manifestations, prognosis, and the controversy surrounding treatment of isolated orbital disease.
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Affiliation(s)
- Curtis E Margo
- Department of Ophthalmology and Pathology, University of South Florida, College of Medicine, Tampa, Florida, USA.
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Ouyang DL, Roberts BK, Gibbs IC, Katznelson L. Isolated Langerhans cell histiocytosis in an adult with central diabetes insipidus: case report and review of literature. Endocr Pract 2007; 12:660-3. [PMID: 17229663 DOI: 10.4158/ep.12.6.660] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report a case of ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS) in a patient with two distinct neuroendocrine tumors and to highlight the difficulties of establishing the differential diagnosis of EAS. METHODS We describe the clinical presentation of the current case, discuss its management, and report the results of molecular studies undertaken to determine whether the two tumors had a common origin. RESULTS A 52-year-old woman presented with obvious features of Cushing's syndrome. Findings on hormonal evaluation were consistent with EAS. Pituitary magnetic resonance imaging revealed normal findings. Computed tomographic imaging disclosed two masses, one in the lung and one in the pancreas. Somatostatin receptor scintigraphy showed uptake only in the pancreatic mass, which was surgically removed. It was a well-differentiated neuroendocrine tumor, with negative immunostaining for ACTH. Hypercortisolemia did not resolve after removal of the pancreatic tumor. The lung mass was subsequently excised, and pathology examination showed a carcinoid tumor with immunostaining for ACTH. Thereafter, plasma ACTH became immeasurable. The two tumors had similar patterns of X-chromosome inactivation; thus, whether they arose independently could be neither confirmed nor excluded. CONCLUSION This case demonstrates that, in the presence of more than one neuroendocrine tumor, somatostatin receptor scintigraphy may misguide the decision regarding the appropriate surgical course in patients with EAS, and it highlights the need for accurate studies to determine the source of ACTH in patients with EAS.
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Affiliation(s)
- Daniel L Ouyang
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Eng TY, Boersma MK, Fuller CD, Luh JY, Siddiqi A, Wang S, Thomas CR. The role of radiation therapy in benign diseases. Hematol Oncol Clin North Am 2006; 20:523-57. [PMID: 16730305 DOI: 10.1016/j.hoc.2006.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although adequate prospective data are lacking, radiation therapy seems to be effective for many benign diseases and remains one of the treatment modalities in the armamentarium of medical professionals. Just as medication has potential adverse effects, and surgery has attendant morbidity, irradiation sometimes can be associated with acute and chronic sequelae. In selecting the mode of treatment, most radiation oncologists consider the particular problem to be addressed and the goal of therapy in the individual patient. It is the careful and judicial use of any therapy that identifies the professional. With an understanding of the current clinical data, treatment techniques, cost, and potential detriment, the goal is to provide long-term control of the disease while minimizing unnecessary treatment and potential risks of side effects. The art lies in balancing benefits against risks.
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Affiliation(s)
- Tony Y Eng
- Department of Radiation Oncology, University of Texas Health Science Center at San Antonio/Cancer Therapy and Research Center, 7979 Wurzbach Road, San Antonio, TX 78229, USA.
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Bruns F, Pruemer B, Haverkamp U, Fischedick AR. Neurosarcoidosis: an unusual indication for radiotherapy. Br J Radiol 2004; 77:777-9. [PMID: 15447966 DOI: 10.1259/bjr/27963001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Up to 70% of patients with systemic sarcoidosis developing neurosarcoidosis do so within the first 2 years of their systemic illness. Central nervous system (CNS) involvement as the only manifestation of sarcoidosis can be seen both at first time of disease and at recurrence in a few isolated cases. A young man showed neurological symptoms caused by isolated CNS sarcoidosis after unsuccessful treatment of primary pulmonary sarcoidosis by steroids. MRI scans of the head showed a distinct structural lesion temporodorsal in the left hemisphere and in the left-sided basal ganglia. The diagnosis was proved by neurosurgical resection. Post-operative systemic treatment with long-term corticosteroids was ineffective. After low-dose whole-brain irradiation of the isolated CNS lesion with 20 Gy, partial resolution of the clinical features and stabilization of disease proved by MRI ensued. In neurosarcoidosis the use of radiation therapy remains an appropriate therapy option with minimal adverse sequelae if primary medical treatment fails.
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Affiliation(s)
- F Bruns
- Department of Radiology, Clemens Hospital Muenster, Düesbergweg 124, D-48153 Muenster, Germany
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18
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Woo KI, Harris GJ. Eosinophilic Granuloma of the Orbit: Understanding the Paradox of Aggressive Destruction Responsive to Minimal Intervention. Ophthalmic Plast Reconstr Surg 2003; 19:429-39. [PMID: 14625488 DOI: 10.1097/01.iop.0000092800.86282.27] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe the findings and outcomes in eosinophilic granuloma (unifocal Langerhans-cell histiocytosis [LCH]) of the orbit and to explain the paradox of aggressive bone destruction responsive to minimal intervention. METHODS Retrospective, consecutive, interventional case series of patients treated from 1985 to 2001. Minimum inclusion criteria were demonstration of CD1a positivity or Birbeck granules, treatment by a single surgeon, systemic evaluation by a pediatric oncologist, and follow-up of 12 months. A pathogenetic construct was assembled from general LCH concepts and the specific orbital findings. RESULTS Seven patients met study criteria. All were male, 2 to 16 years of age. All had eyelid or forehead swelling and osteolytic defects, with symptoms of 2 to 6 weeks' duration. All underwent incisional biopsy, with frozen-section examination suggestive of LCH in 6 of 7 cases. The 2 earliest patients received low-dose irradiation after simple biopsy. The 5 most recent patients had subtotal curettage at the time of biopsy; 4 of 5 received simultaneous intralesional corticosteroid injection. In all cases, systemic evaluation showed no other focus of LCH, reossification was timely, and no local recurrence or additional focus was noted in follow-up of 1 to 17 years. CONCLUSIONS Transient immune dysfunction may provoke the cytokine-mediated proliferation of pathologic Langerhans cells within the hematopoietic marrow of the anterolateral frontal bone. These cells cause osteolysis through elaboration of interleukin-1 and prostaglandin E2. Corticosteroids can inhibit the mediators. We recommend incisional biopsy, frozen-section provisional diagnosis, subtotal curettage, intralesional corticosteroid instillation, postoperative systemic evaluation, and long-term surveillance.
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Affiliation(s)
- Kyung In Woo
- Section of Orbital and Ophthalmic Plastic Surgery, Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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19
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Calming U, Bemstrand C, Mosskin M, Elander SS, Ingvar M, Henter JI. Brain 18-FDG PET scan in central nervous system langerhans cell histiocytosis. J Pediatr 2002; 141:435-40. [PMID: 12219070 DOI: 10.1067/mpd.2002.127087] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We used positron emission tomography (PET) to characterize cerebral metabolism in 7 patients (serial examinations in 2 patients) with central nervous system disease in Langerhans cell histiocytosis (CNS-LCH) who had neuroendocrine abnormalities (n = 7), neuropsychiatric disabilities (n = 3), and CNS degenerative disease (n = 1). The PET scan alterations occurred at localizations with known CNS-LCH disease. The PET scans revealed areas where the metabolism and function were altered in 6 of the 7 patients studied, with either an increased or a decreased metabolism (uptake of glucose). Serial examinations may indicate alterations in the degree of ongoing disease activity, but further studies on functional imaging are desired. The additional information of PET compared with MRI is the ability to detect alterations in CNS metabolic activity in certain patients with CNS-LCH. PET may also provide a tool for longitudinal follow-up of therapeutic measures in selected patients.
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Affiliation(s)
- Ulrika Calming
- Karolinska Hospital, Karolinska Institute, Stockholm, Sweden
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20
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Behrens RJ, Levi AW, Westra WH, Dutta D, Cooper DS. Langerhans cell histiocytosis of the thyroid: a report of two cases and review of the literature. Thyroid 2001; 11:697-705. [PMID: 11484900 DOI: 10.1089/105072501750362781] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Langerhans cell histiocytosis (LCH) is a monoclonal disease of histiocytes that can involve many or very few organ systems. It is a relatively benign disorder with a 3% mortality in adults. LCH rarely involves the thyroid gland. We report two cases, both presenting in males with a goiter. Both patients were treated with subtotal thyroidectomy. The first patient also received radiotherapy to his thyroid bed and scalp. We summarize the prior reported cases of LCH involving the thyroid and review the current treatment modalities used for LCH.
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Affiliation(s)
- R J Behrens
- National Cancer Institute, Bethesda, Maryland, USA
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21
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Sohn MJ, Park HC, Park HS, Kim JJ, Kim EY. Anterior cervical corpectomy and fusion using miniplate and screws in a 7-year-old child with eosinophilic granuloma of the cervical spine. Spine (Phila Pa 1976) 2001; 26:1193-6. [PMID: 11413437 DOI: 10.1097/00007632-200105150-00023] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a case report of a 7-year-old child with eosinophilic granuloma in the cervical spine, which underwent anterior cervical corpectomy and fusion by using Miniplate and screws. OBJECTIVES To describe the use of Miniplate and screws for pediatric cervical anterior fusion. SUMMARY OF BACKGROUND DATA Eosinophilic granuloma is a rare disease causing destructive bony lesions of the cervical spine in children. A complete resection and fusion were considered to be the preferable treatment in our case. However, cervical spinal fusion and instrumentation in children may be technically difficult because of the size of the vertebral body and the iliac bone. In addition, a proper device for an internal fixation in pediatric patients is not yet available. METHODS A case of eosinophilic granuloma in pediatric spine was presented. RESULTS We confirmed successful bony fusion and the restoration of the normal cervical curvature without recurrence of the tumor 2 years after the procedure. CONCLUSIONS For proper internal fixation and prevention of dislodgement of the grafted bone, we used the Miniplate and screws as internal fixator after intralesional resection of the tumor mass.
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Affiliation(s)
- M J Sohn
- Department of Neurosurgery, Inha University Medical Center, Inchon, Korea
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22
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Abstract
Cutaneous involvement in Langerhans cell histiocytosis (LCH) occurs in 50% of cases and may be the presenting feature. It is, therefore, important to recognize the wide spectrum of clinical disease that this disorder may adopt in the skin. Cutaneous involvement is not necessarily a benign feature and many patients progress to multi-system disease. There are a number of treatments available for cutaneous LCH. The rationale is to start with the simplest treatment and progress to systemic or interventional therapy as needed.
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Affiliation(s)
- S Munn
- Imperial College School of Medicine, London, United Kingdom
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23
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Baumgartner I, von Hochstetter A, Baumert B, Luetolf U, Follath F. Langerhans'-cell histiocytosis in adults. MEDICAL AND PEDIATRIC ONCOLOGY 1997; 28:9-14. [PMID: 8950330 DOI: 10.1002/(sici)1096-911x(199701)28:1<9::aid-mpo3>3.0.co;2-p] [Citation(s) in RCA: 157] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Guided by a long-term retrospective observation, the clinical course and treatment of Langerhans'-cell histiocytosis (LCH) in adult patients are represented. The series included 19 patients meeting the histopathologic criteria of presumptive LCH who were followed for 1.5-20 years (average 7.7 years). Most frequently, skeletal lesions (16 patients), diffuse interstitial lung infiltrates (seven patients), and pituitary gland involvement with diabetes insipidus (four patients) were present. Bone lesions of the skull and axial skeleton were associated with an infiltration of adjacent soft tissues in 10 of 16 patients. Liver, lymph node, and bone marrow involvement appeared sporadically. LCH was divided into localized or multifocal form. Localized disease took a benign course with remission of bone (n = 4) or lymph node lesions (n = 2). Also, in isolated pulmonary LCH (n = 2), spontaneous transition to inactive disease occurred. With the exception of isolated bone lesions (n = 27), which remained asymptomatic or showed a remission to treatment, multifocal LCH had a more aggressive course. Osseous lesions with adjacent soft tissue infiltration (n = 20) showed a relapse rate in excess of 80% independent of the treatment applied. Pulmonary involvement led to a more marked functional impairment compared to the isolated form, and systemic treatment yielded no convincing effect. In three patients with liver or bone marrow involvement, LCH showed a persistent, serious disease activity. One patient died of transition into acute monomyelocytic leukemia 18 months after diagnosis without preceding chemotherapy. In adults, LCH seems to be limited to a few organ systems. Multifocal LCH represents the more aggressive form with unfavorable prognosis in patients with bone lesions spreading into the adjacent soft tissue and liver or bone marrow involvement.
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Affiliation(s)
- I Baumgartner
- Department of Internal Medicine, University Hospital, Zürich, Switzerland
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Sakai H, Ibe M, Takahashi H, Matsuo S, Okamoto K, Makino I, Oomori Y, Iizuka H. Satisfactory remission achieved by PUVA therapy in Langerhans cell hisiocytosis in an elderly patient. J Dermatol 1996; 23:42-6. [PMID: 8720257 DOI: 10.1111/j.1346-8138.1996.tb03966.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Langerhans cell histiocytosis is currently regarded as a reactive proliferative process of Langerhans cells rather than a malignancy. The disease is characterized by Langerhans cell infiltration of skin, lung, bone and other organs. We report a 74-year-old man with Langerhans cell histiocytosis who had generalized hemorrhagic and crusted papules. He also had diabetes insipidus. Because he did not have any severe constitutional symptoms or failure of vital organs, we applied topical PUVA treatment to his skin lesions, which responded well to the therapy. Diabetes insipidus, however, remained, in spite of X ray radiotherapy for the pituitary lesion.
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Affiliation(s)
- H Sakai
- Department of Dermatology, Asahikawa Medical College, Japan
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25
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Grois N, Flucher-Wolfram B, Heitger A, Mostbeck GH, Hofmann J, Gadner H. Diabetes insipidus in Langerhans cell histiocytosis: results from the DAL-HX 83 study. MEDICAL AND PEDIATRIC ONCOLOGY 1995; 24:248-56. [PMID: 7700170 DOI: 10.1002/mpo.2950240407] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Diabetes insipidus (DI) in Langerhans cell histiocytosis (LCH) is a common complication of unclear etiology. The incidence varies among different publications from 15% to 50%. In the prospective DAL-HX 83 study, 19 out of 199 patients (9.5%) registered with newly diagnosed LCH were diagnosed to have DI. All patients were stratified according to uniform criteria. One hundred and six patients with disseminated disease were treated with standardized polychemotherapy promptly after diagnosis. At the time of diagnosis of LCH, DI was already established in 8 out of 199 patients (4%). After diagnosis, DI occurred in only one out of the remaining 91 patients with localized disease (1%) and in 10 out of 100 remaining patients with disseminated disease (10%). In 8 patients, the onset of DI was associated with other signs of active LCH. The cumulative risk to develop DI after a median observation time of 5 years 3 months was 11%. Retrospective analysis of clinical features revealed multisystem involvement, skull and orbital lesions, and in particular intracranial extension from osseous lesions to constitute risk factors for DI. Magnetic resonance imaging studies (MRI) were available in 12 patients and showed abnormalities of the pituitary region in 10 children. In none of the patients with established DI was it reversed or ameliorated by any treatment. However, the rapid institution of systemic chemotherapy for disseminated disease seems to prevent the occurrence of DI and may be responsible for the low frequency of DI in the DAL-HX83 study.
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Affiliation(s)
- N Grois
- St. Anna Children's Hospital, Vienna, Austria
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26
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McClain KL, Hutter JJ, Cassady JR. Langerhans Cell Histiocytosis. RADIATION THERAPY IN PEDIATRIC ONCOLOGY 1994. [DOI: 10.1007/978-3-642-84520-8_22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Gadner H, Heitger A, Grois N, Gatterer-Menz I, Ladisch S. Treatment strategy for disseminated Langerhans cell histiocytosis. DAL HX-83 Study Group. MEDICAL AND PEDIATRIC ONCOLOGY 1994; 23:72-80. [PMID: 8202045 DOI: 10.1002/mpo.2950230203] [Citation(s) in RCA: 188] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Treatment of Langerhans cell histiocytosis (LCH) remains problematic. To test the hypothesis that rapid initiation and long-term continuation of chemotherapy can improve survival and reduce recurrence and late consequences of disseminated LCH, we have completed a prospective clinical trial (DAL HX-83). One hundred six newly diagnosed patients were stratified into three risk groups (A: multifocal bone disease [n = 28]; B: soft tissue involvement without organ dysfunction [n = 57]; C: organ dysfunction [n = 21]). All patients received an identical initial 6-week treatment (etoposide [VP-16], prednisone, and vinblastine), and continuation treatment for 1 year, slightly adapted according to stratification at diagnosis. It included oral 6-mercaptopurine and eight pulses of vinblastine and prednisone for all patients, plus VP-16 in group B and VP-16 and methotrexate in group C. Eighty-nine percent and 91% of patients in groups A and B and 67% of the most severely affected group C, achieved complete resolution of disease. The speed of resolution was rapid (median 4 months) and independent of disease severity. The frequency of recurrence after initial resolution was low (12%, 23%, and 42% in groups A, B and C); overall fully 77% of patients have remained free of recurrence. Permanent consequences developed after diagnosis in 20% of the patients. Diabetes insipidus after initiation of treatment occurred in only 10% of patients. Mortality (9%) was limited to patients of groups B (two patients) and C (eight patients). Finally, among the 106 patients treated by DAL HX-83 none have developed a malignancy (median follow-up 6 years, 9 months). The shorter duration of active disease, low rate of recurrence and permanent consequences, and improved survival among patients with poor prognosis support the strategy of rapid initiation of a predefined prolonged treatment upon the diagnosis of disseminated LCH.
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Affiliation(s)
- H Gadner
- St. Anna Children's Hospital, Vienna, Austria
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28
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Acciarri N, Paganini M, Fonda C, Gaist G, Padovani R. Langerhans cell histiocytosis of the spine causing cord compression: case report. Neurosurgery 1992; 31:965-8. [PMID: 1436427 DOI: 10.1227/00006123-199211000-00025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A case of Langerhans cell histiocytosis of the spine causing myeloradiculopathy is reported. Almost complete regression of symptoms and signs was observed in the patient after surgical treatment and radiotherapy. The clinical and histological features of the disease are discussed. The literature dealing with the previously reported cases of spinal histiocytosis involving neural structures is reviewed.
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Affiliation(s)
- N Acciarri
- Department of Neurosurgery, Bellaria Hospital, Bologna, Italy
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29
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Langerhans Cell Histiocytosis of the Spine Causing Cord Compression. Neurosurgery 1992. [DOI: 10.1097/00006123-199211000-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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30
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Literature Review. J Pediatr Oncol Nurs 1990. [DOI: 10.1177/104345429000700309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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